Work-related asthma--38 states and District of Columbia, 2006-2009

Work-related asthma (WRA) includes work-exacerbated asthma (preexisting or concurrent asthma worsened by factors related to the workplace environment) and occupational asthma (new onset asthma attributed to the workplace environment). WRA is a preventable occupational lung disease associated with serious adverse health and socioeconomic outcomes. Among workers with similar occupational exposures, WRA diagnosis offers unique opportunities for prevention. The American Thoracic Society estimated that 15% of U.S. adults with asthma have asthma attributable to occupational factors. State-level information on the proportion of asthma that is WRA is limited but could be useful to prioritize and guide investigations and interventions. To estimate current asthma prevalence and the proportion of asthma that is WRA, CDC analyzed data from the 2006-2009 Behavioral Risk Factor Surveillance System (BRFSS) from 38 states and the District of Columbia (DC). This report summarizes the results of that analysis, which indicated that among ever-employed adults with current asthma, the overall proportion of current asthma that is WRA was 9.0%. State-specific proportions of asthma that are WRA ranged from 4.8% to 14.1%. Proportions of WRA were highest among persons aged 45-64 years (12.7%), blacks (12.5%), and persons of other races (11.8%). These findings provide a baseline that state and national health agencies can use to monitor the proportion of WRA among persons with current asthma. Enhancing WRA surveillance through routine collection of industry and occupation information will greatly increase understanding of WRA.     

Clinical evaluation, management, and prevention of work-related asthma

Work-related asthma (WRA) is asthma that is attributable to, or is made worse by, environmental exposures in the workplace. WRA has become the most prevalent occupational lung disease in developed countries, is more common than is generally recognized, and can be severe and disabling. Identification of workplace exposures causing and/or aggravating the asthma, and appropriate control or cessation of these exposures can often lead to reduction or even complete elimination of symptoms and disability. This depends on timely recognition and diagnosis of WRA. In this review, the diagnostic evaluation has been organized in a stepwise fashion to make it more practical for primary care physicians as well as physicians specializing in occupational diseases and asthma. WRA merits more widespread attention among clinicians, labor and management health and safety specialists, researchers, health care organizations, public health policy makers, industrial hygienists, and others interested in disease prevention.     

Fifteen-year trends in occupational asthma: data from the Shield surveillance scheme

Background Trends of occupational asthma (OA) differ betweenregions depending on local industries, provisions for healthand safety at the workplace and the availability of a reportingscheme to help in data collection and interpretation. Aim To assess trends in OA in an industrialized part of theUK over a 15-year period. Methods Occupational and chest physicians in the West Midlandswere invited to submit details of newly diagnosed cases withOA. Data were then transferred to the regional centre for occupationallung diseases for analysis. Results A total of 1461 cases were reported to the scheme. Sixty-eightper cent were males with mean (standard deviation) age of 44(12) years. The annual incidence of OA was 42 per million ofworking population (95% CI = 37–45). OA was most frequentlyreported in welders (9%) and health care-related professions(9%) while <1% of cases were reported in farmers. Isocyanateswere the commonest offending agents responsible for 21% of reportsfollowed by metal working fluids (MWFs) (11%), adhesives (7%),chrome (7%), latex (6%) and glutaraldehyde (6%). Flour was suspectedin 5% of cases while laboratory animals only in 1%. Conclusions Our data confirm a high annual incidence of OA inthis part of the UK. MWFs are an emerging problem, while isocyanatesremain the commonest cause. Incidence remained at a fairly stablebackground level with many small and a few large epidemics superimposed.Schemes like Midland Thoracic Society's Rare Respiratory DiseaseRegistry Surveillance Scheme of Occupational Asthma could helpin identifying outbreaks by linking cases at the workplace.     

Prevention of occupational asthma--practical implications for occupational physicians

BACKGROUND: Occupational factors have been estimated to contribute to approximately 10% of adult-onset asthma and occupational asthma (OA) is one of the most common occupational lung diseases in industrialized areas. Persistent asthma frequently occurs with significant socio-economic impacts. METHODS: A literature search was performed using PubMed. The key term searched was occupational asthma combined with prevention. RESULTS: Primary prevention has been effective for OA related to natural rubber latex, and may have reduced the incidence of diisocyanate-induced asthma. Medical health surveillance has been effective in settings such as the detergent enzyme industry, workers exposed to complex platinum salts and likely for diisocyanate workers in Ontario. Tertiary prevention is still required for workers with OA and can improve prognosis. CONCLUSIONS: OA is potentially preventable. Sufficient studies have demonstrated the rationale and benefit of primary preventive strategies. Medical health surveillance programs combined with occupational hygiene measures and worker education have been associated with improved outcomes but further studies are needed to understand the optimum frequency and measures for such programs and to identify the separate contribution of the components. Until primary and secondary prevention is better understood and implemented, there will also remain a need for tertiary preventive measures.     

Is atopy and smoking important in the workplace?

The relationship between the respiratory system and the environment involves a complex dynamic interaction of genetic susceptibility, host defence and toxicity. The chance of an individual developing a respiratory disease is dependent on genetic susceptibility and subsequent hereditary risk factors, life-style risk factors and the amount and nature of the exposure that may be encountered in the working environment. Atopic status is an important pre-existing risk that a worker may bring to the workplace (occupational asthma/rhinitis to high molecular weight agents). Smoking is an avoidable additional risk for certain occupational diseases (occupational asthma/bronchitis/cancer) while it can be protective in other circumstances (allergic alvcolitis). More controversially, smoking in some workers may put at increased risk the health of colleagues (passive smoking). This article attempts to clarify the issues surrounding the interaction of atopy, smoking and the workplace.     

Algae-induced occupational asthma in a thalassotherapist

BACKGROUND: Algae powders have been increasingly used in therapeutic preparations. Their potential as inducers of occupational asthma (OA), however, remains to be demonstrated. METHODS: A 33-year-old woman developed asthma following exposure to algae powder used for thalassotherapy. She had positive patch tests to nickel and cobalt in an evaluation for intermittent skin rash. At work, she had a normal forced expiratory flow in 1 s (FEV(1)) but moderate airway hyperresponsiveness. Bronchial provocation tests (BPT) were obtained. RESULTS: On BPT, an isolated early response was observed after a 1-min inhalation of dry algae powder, with a 50% fall in FEV(1) after exposure; the control BPT with lactose powder was negative. CONCLUSIONS: We report a case of algae-powder-induced OA. Such responses could be due to a sensitization to algae proteins or metal contaminants bioabsorbed by the vegetal particles.     

Work-related asthma among professional cleaning women

The job of cleaning has developed dynamically as a working service, and women constitute the majority of all professional cleaning workers. Cleaners are at an increased risk of work-related asthma (WRA). This study characterizes work-related respiratory symptoms reported by female cleaners, evaluates any associated factors of WRA, and shows diagnostic management of medical certification. The study group comprised 50 professional cleaning women referred to our Occupational Diseases Department due to suspicion of occupational asthma (OA). A questionnaire, skin prick tests, serum specific IgE antibodies, and specific inhalant challenge were performed in all of the participants. Work-related asthma was recognized in 46% of symptomatic cleaners, of whom 15 were considered as having work-exacerbated asthma (WEA) and 8 as having OA. Sensitization to latex and disinfectants played an important role as a causative agent in OA of cleaners.     

Occupational asthma in New South Wales (NSW): a population-based study

BACKGROUND: The proportion of asthma in adults that is due to occupational exposures is not known. AIM: To examine the contribution of workplace exposures to the development of asthma in adults in New South Wales (NSW) in a cross sectional, population-based study. METHODS: A randomly selected population of 5,331 18- to 49-year olds completed and returned a mailed questionnaire (response rate 37%). In adult-onset asthmatics we examined the association of asthma with reported exposure, within 1 year of asthma onset, to a list of occupations and exposures known to be at risk for occupational asthma (high-risk jobs and exposures). RESULTS: Among 910 subjects (18%) with asthma, 383 (7%) subjects reported adult-onset disease. After adjusting for sex, age and smoking, working in any high-risk job or exposure at the time of asthma onset was significantly associated with adult-onset asthma (OR 1.51, 95% CI 1.19-1.92). The population attributable risk (PAR) of adult-onset asthma for either a high-risk job or an exposure was 9.5%. Sudden onset, irritant or reactive airways dysfunction syndrome type exposures were associated with adult-onset asthma (OR 4.65, 95% CI 1.64-13.2). The PAR of adult-onset asthma for these exposures was 0.2%. CONCLUSION: Reported adult onset of asthma is common and occupational exposures may be associated with 9.5% of prevalent cases of adult-onset asthma in NSW.     

Screening questionnaires for bakers' asthma--are they worth the effort?

The use of a respiratory screening questionnaire is recommendedannually to screen bakery workers in the UK. We compared questionnairescreening with other methods of detecting workers with asthmaticsymptoms and then assessed the significance of these symptomswith careful investigation and follow-up. Reasons for questionnairefailures were then explored. A questionnaire was issued to 362flour-exposed workers in a large bakery. All positive respondentsto respiratory symptom questions were interviewed by an occupationalnurse. Workers with occupationally related symptoms at thisinterview were referred to the chest clinic. In addition, workerswith negative questionnaires were screened using attendancerecords, sick notes and direct workplace observations. Workerswith frequent absence from work or sick notes with respiratorydiagnoses were interviewed in the same manner as those answeringthe questionnaire positively and then referred to clinic. Atclinic, a diagnosis was made for each worker on the basis ofclinical assessment, spirometry, serial peak expiratory flowrate (PEFR) analysis and radioallergosorbent testing (RAST)testing for specific IgE. Using the clinic diagnoses, the referralroutes were audited to assess the rates of case detection ofasthma and occupational asthma. The respiratory screening questionnaireidentified 68 workers with respiratory symptoms. Of these, 21proceeded to full assessment. A diagnosis of asthma was madein five cases, one of which was bakers' asthma. In addition,11 workers not reporting any symptoms by questionnaire werereferred to clinic and five were diagnosed as having asthma.Screening questionnaires may lead to an underestimate of theprevalence of asthmatic symptoms and as such should not be usedalone in workplace screening.     

Work-related asthma and implications for the general public

Asthma has been increasing over the last two decades in the United States. The onset of asthma has also been increasingly reported as a result of occupational exposures to over 350 different agents. Work-related asthma (WRA) has become the most frequently diagnosed occupational respiratory illness. Epidemiologic studies from the United States reported WRA incidence rates of 29-710 cases per million workers per year and suggest that 10-25% of adult asthma is work related. Much can be learned about asthma in the general population from investigations of asthma in the workplace. Surveillance of WRA continues to highlight an important role for low molecular weight chemical sensitizers, as well as high molecular weight antigens. Additionally, recent reports implicate mixed exposures, including commercial cleaning solutions, solvents, and other respiratory irritants, as well as contamination in nonindustrial environments, including schools and offices. Investigations of WRA have demonstrated a clear dose-related increase in sensitization and symptoms for exposures to both chemical and protein sensitizers. High proportions of exposed working groups can be affected. Skin exposures may affect the likelihood of individuals developing respiratory symptoms. Atopy increases the risk of sensitization and illness from workplace exposure to antigens but not to chemical sensitizers. Irritant exposures can act as adjuvants among individuals exposed to sensitizing substances, increasing the proportion who become sensitized. Atopy might also be a result of irritant exposures in some persons. Occupational asthma often has important long-term adverse health and economic consequences but can resolve completely with timely control of exposures. Detailed study of such asthma "cures" may prove useful in understanding factors that influence asthmatic airway inflammation in the general population.     

Current best practice for the health surveillance of enzyme workers in the soap and detergent industry

This study defines current best practice for the health surveillance of workers who are potentially exposed to enzymes in the manufacture of enzymatic detergent products. It is recommended that health surveillance is performed 6-monthly for the first 2 years and annually thereafter. The health surveillance programme should include a respiratory questionnaire to detect symptoms, assessment of lung function to detect pre-symptomatic changes and an immunological test to detect specific immunoglobulin E (IgE) to enzymes. The International Union Against Tuberculosis and Lung Disease respiratory questionnaire should be used since it has been validated extensively for detecting asthma. Operators should observe the American Thoracic Society performance criteria for spirometers and standardized procedures for conducting spirometry. Since current airborne monitoring techniques for enzymes do not detect short-duration peak exposures, the incidence of employee sensitizations remains the most reliable measure of the integrity of environmental control. The Pepys skin prick test has been validated as a sensitive, specific and practical test for detecting specific IgE to many inhalant allergens including enzymes. For newly sensitized workers, a multi-cause investigation should be conducted to identify potential sources of exposure. Group results of immunological test results assist in the evaluation of workplace control measures, and should be used to monitor the effectiveness of hygiene and engineering programmes and to help prioritize areas for improvement. Positive responses to a questionnaire or abnormal spirometry should be assessed further. Occupational asthma should be excluded in any case of adult-onset asthma that starts or deteriorates during working life. This is particularly important because an accurate diagnosis of occupational asthma with early avoidance of exposure to its cause can result in remission of symptoms and restoration of lung function.     

Opportunities and obstacles in translating evidence to policy in occupational asthma

Purpose

Occupational asthma (OA), a common respiratory disorder in Western countries, is caused by exposures at the workplace. It is part of a broader definition of work-related asthma (WRA) that also includes pre-existing asthma aggravated by substances present in the workplace environment, and it is potentially preventable. The purpose of this paper is to illustrate preventive measures for occupational asthma by case studies.

The Bristol Stress and Health Study: accidents, minor injuries and cognitive failures at work

BACKGROUND: Accidents and injuries at work account for several million working days lost each year. Cognitive failures (problems of memory, attention or action) can lead to accidents and injuries in certain contexts. AIM: This work describes the prevalence and associations of workplace accidents, minor injuries and cognitive failures reported by respondents to a follow-up postal questionnaire as part of the community-based Bristol Stress and Health Study. METHODS: Postal questionnaires were sent to 4673 people who participated in the first phase of the study (in which questionnaires were sent to individuals selected at random from the electoral roll). RESULTS: Four per cent of workers reported an accident at work, 8% reported quite or very frequent minor injuries and 13% reported quite or very frequent cognitive failures. Accidents at work were associated with being male, smoking and higher negative job characteristics. Respondents reported workplace accidents at a level similar to the overall UK rate. Accidents and minor injuries, and minor injuries and cognitive failures, shared common associations and all three outcomes were associated with each other. CONCLUSION: Information about cognitive failures is important in the study of accidents and injuries at work. In addition, negative job characteristics represent part of the context in which human error is translated into injury.     

Fatal asthma from powdering shark cartilage and review of fatal occupational asthma literature

BACKGROUND: Work-related asthma (WRA) is the most common work-associated respiratory disease in developed countries. METHOD: We report shark cartilage dust as a new potential cause of occupational asthma (OA) in the context of other fatal OA case reports. RESULTS: A 38-year-old white male worked for 8 years in a facility which primarily granulated and powdered various plastics. Sixteen months prior to his death, the plant began grinding shark cartilage. After 10 months of exposure, he reported chest symptoms at work in association with exposure to shark cartilage dust and a physician diagnosed asthma. Six months later, he complained of shortness of breath at work and died from autopsy-confirmed asthma. The latency from onset of exposure to symptoms and from symptom onset to death was shorter than 10 previously reported OA fatalities. CONCLUSION: Recognition of occupational causes and triggers of asthma and removal of affected individuals from these exposures is critical and can prevent progression to irreversible or even fatal asthma.     

Sensitization to king scallop (Pectin maximus) and queen scallop (Chlamys opercularis) proteins

OBJECTIVE: To report a case of occupational asthma and urticaria due to the queen scallop (Chlamys opercularis) and king scallop (Pectin maximus). BACKGROUND: A 40-year-old female worked in a shellfish-processing plant, handling king and queen scallops for 5 years. At the time of investigation, she described a 2-year history of work-related respiratory symptoms. METHODS: Serial peak expiratory flow rate readings were recorded and an OASYS study completed. A workplace visit was undertaken and specific immunoglobulin (IgE) radioallergosorbent (RAST) testing of scallop extracts was performed. RESULTS: The OASYS study was consistent with occupational asthma. RAST testing demonstrated evidence of specific sensitization (IgE) to queen and king scallop. There was also some cross-reactivity observed with other shellfish (prawns and crabs). CONCLUSION: Workers exposed to aerosols from scallop species are at risk of occupational asthma and require effective respiratory health surveillance.     

Occupational asthma and rhinitis caused by 1,2-benzisothiazolin-3-one in a chemical worker

We report a case of occupational asthma and rhinitis causedby inhalation of 1,2-benzisothiazolin-3-one, an additive usedas a microbicidal in detergent production, in a 26-year-oldman employed in a chemical factory producing detergents. Thesubject's task consisted of pouring raw materials into the recipientof a machine which mixed the substances. Two months after thebeginning of this job the patient complained of rhinitis andasthma at the workplace. The specific challenge test with 1,2-benzisothiazolin-3-one,one of the raw materials to which the subject was exposed, provokedan immediate prolonged asthmatic response and nasal symptoms,whereas exposure to other agents (e.g., -amylase, alcalase orbezalkonium chloride) to which the patient was also exposedat work did not. To our knowledge this is the first case ofoccupational asthma and rhinitis caused by this compound.     

Evidence-based decision making in an endoscopy nurse with respiratory symptoms exposed to the new ortho-phthalaldehyde (OPA) disinfectant

BACKGROUND: ortho-Phthalaldehyde (OPA) can cause mucous irritation, respiratory symptoms and IgE-mediated hypersensitivity reactions. Very little information is available about OPA-related effects in health personnel. AIM: To report the decision-making process for the case of an endoscopy nurse complaining of cough and burning of the nose and throat during OPA exposure at work. METHODS: The problem focused on the relationship between OPA exposure and the respiratory symptoms and was investigated using an evidence-based (EB) medicine paradigm. RESULTS: A literature search was performed using the database Medline and the search engine Google. Papers and guidelines were assessed for their suitability in the EB case identification of suspected occupational asthma (OA). A multistep approach suggested by a guideline was considered most appropriate for practical use. The nurse shared the decision-making process and underwent evaluation of the clinical suspicion index and interventions for diagnosis of OA. Despite the high clinical suspicion index, the diagnosis of OA was excluded and any work restriction was avoided. Health surveillance follow-up showed a good clinical outcome and prompt recovery from respiratory symptoms after improvement of environmental control measures. CONCLUSION: The case study shows that the implementation of EB guidelines provides the occupational physician with an appropriate decision-making process for the identification and management of workers with suspected OA. Screening out of OA is highly relevant because diagnosis of disease requires removal from exposure and frequently impacts negatively on worker employment.     

The effects of asthma on the quality of life and employment of construction workers

Relatively little is known about the consequences of asthma for patients' work ability. In particular, the relationship between asthma and construction work has not been studied previously. The aim of this study was to determine how asthma affects construction workers' work ability and quality of life, and the most important conditions that cause respiratory symptoms in construction work. A questionnaire was sent to all construction workers examined in the pulmonary clinic of Tampere University Hospital between 1991 and 1995 who were diagnosed as having 'asthma bronchiale' (n = 104). In addition, 206 non-asthmatic construction workers were recruited from the register of the local trade union. Altogether, 73% of the asthmatic construction workers and 70% of the controls completed the questionnaire. Of the asthmatics, 48% were retired, whereas only 24% of the controls were receiving a pension. The asthmatics evaluated their work ability and general health as significantly worse than did the controls. The asthmatics had more limitations in their work and everyday life than the controls. Asthmatic construction workers had often changed work tasks and also occupation because of their illness. Building renovation, cleaning and insulation with mineral fibre materials were the most common causes of respiratory symptoms in the workplace, among both the asthmatics and the controls. Cold air, physical exercise and all types of dust and smoke caused the asthmatics to experience symptoms. It was concluded that asthma limits the work and everyday life of construction workers. Exposure to dusty, non-sensitizing agents is associated with asthmatic symptoms among construction workers.     

Self-reported work-related health problems from the Oslo Health Study

BACKGROUND: Lack of knowledge about the occurrence of work-related health problems in the general population makes it difficult to estimate the potential for their prevention in the workplace. AIMS: To examine the prevalence of self-reported work-related health problems among adult citizens of Oslo, Norway. METHODS: The study was part of the Oslo Health Study 2000-2001, in which all individuals in certain age cohorts were invited to a comprehensive health screening. All 30-, 40- and 45-year old subjects who attended the screening were asked if they had experienced any of 11 common health problems in the past month, and whether they considered these to be work-related. Of the 26,074 invitees in these age cohorts, 8,594 (33%) answered the questionnaire. RESULTS: Nearly 60% of subjects reported one or more work-related health problems, most commonly reported were pain in the neck/shoulders (38%) and low back pain (23%). Neck/shoulder pain was most frequently attributed to working conditions, by 74% of subjects with this problem; followed by arm pain (72%), fatigue (51%) and low back pain (50%). Work-related fractions for eczema and asthma symptoms were 23 and 18%, respectively. There were marked gender differences, but small age differences. CONCLUSIONS: A substantial proportion of common health problems in the Oslo population were attributed to working conditions. This implies a large preventive potential and call for increased preventive efforts targeted at known risk factors in the workplace.